Approved form AF2002-246

Approved by the General Manager of the Health Protection Service on 6.12.2002 under the

Public Health Act 1997, s137A

Public Health Act 1997—Form BH5
(see s36)
Australian Capital Territory

Boarding House Activity Licence Transfer Form

(See attached Boarding House Activity Licence Transfer Form)

Section 1 - Conditions of Transfer
•	This application must be signed by both the current licensee and the new applicant;
•	The original licence must be submitted with this transfer application; and
•	This form must be completed and returned with the prescribed fee.
If these conditions cannot be met the new applicant must complete a new application form
Section 2- Current Licence Details

Licence No:			File No:			Expiry Date:		

Section 3 - Fees
Transfer Fee $50 
•	Charities and Benevolent Institutions are fee exempt.  Please supply documentary evidence from the Australian Taxation Office.
•	GST is not applicable under section 81-5 of the A New Tax System (Goods and Services Tax) Act 1999 (C’th).
Section 4 - Current Licensees' Details 
1	Current Licensee		
Title		First Name		Surname			
ABN		Company		
2	Current Business Details		
Trading Name			
3	Current Contacts		
Contact Person for Licensee			
Business - Manager			
4	Current Business Contact Details		
Phone		Fax		Mobile			
E-Mail			
Section 5 - Transfer Details
5	Current Licensee to Complete:		
Please transfer this businesses' licence to the new entity below	
Signature of Licensee		Date			
Print Name					
6	New Licensee to Complete: (Note: The New licensee is required to sign the Declaration at Section 8 - Page 2 of this form)	
A)	Business Details		
New Trading Name			
B)	New Licensee 		
Title		First Name		Surname			
ABN		Company			

Section 6 - New Contact Details
7	Contacts		
Contact Person for Licensee			
Business - Manager			
8	Business Contact Details		
Phone		Fax		Mobile			
E-Mail			
9	Licensees' Contact Details  -  Same as Question 8 		
Phone		Fax		Mobile			
E-Mail			
Section 7 - New Postal Details
10	Business Postal Address		

Suburb		State		Postcode			
11	Postal Address for Licensing Correspondence  -  Same as Question 10 		

Suburb		State		Postcode			
Section 8 - Declaration (New Applicant to Sign)
I declare that all the information supplied on this form is true and correct and necessary records and / or documentation exist to support this application.	
Signature of Applicant		Date			
Print Name		Position
Title			
OFFICE USE ONLY
Transfer Approved 	Yes  No  	Conditions 	Yes  No 	Officer's Signature _______________________ Date __________

PLEASE SEE SECTION 9 - PAGE 3 FOR PAYMENT OPTIONS 

Section 9 - Payment
Payment Method - Please Tick ()	Cash 	Cheque 	Credit Card 	
Note: Cheques should be made payable to the Health Protection Service. 	
Contact Person			
				
Type of Credit Card - Please Tick ()	Visa 	Master Card 	Bankcard 	
Credit Card No	Expiry Date	
   	/	
Cardholders' Name			
		
Fee	$ 50		
I agree for the Health Protection Service to debit my account for the above fee.	
Card Holder's Signature		Date			
Daytime Phone No					
How to Pay		
	By Mail: Health Protection Service, Locked Bag 5, Weston Creek  ACT  2611.		In Person: Health Protection Service, 25 Mulley Street, Holder ACT.	
	Fax: 6205 1705 			
Note: For fax payments you are still required to sign and return this form prior to the issue of your licence.	

OFFICE USE ONLY
File No: _________________			 Licence No _____________________

Form – BH5